| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
1,666 |
1,647 |
$232K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,089 |
334 |
$161K |
| D1351 |
Sealant - per tooth |
5,564 |
1,029 |
$152K |
| D1120 |
Prophylaxis - child |
2,477 |
2,458 |
$89K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
818 |
348 |
$77K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,607 |
2,712 |
$74K |
| D2335 |
|
439 |
135 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
1,781 |
1,769 |
$51K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,464 |
1,394 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
3,029 |
2,979 |
$37K |
| D0240 |
|
3,228 |
1,996 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
880 |
875 |
$30K |
| D1206 |
Topical application of fluoride varnish |
1,897 |
1,886 |
$27K |
| D0272 |
Bitewings - two radiographic images |
1,062 |
1,057 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
626 |
621 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
124 |
55 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
66 |
40 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
300 |
294 |
$5K |
| D0350 |
|
215 |
205 |
$4K |
| D1110 |
Prophylaxis - adult |
40 |
40 |
$2K |
| D1330 |
|
133 |
128 |
$1K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$892.92 |
| D0603 |
|
4,513 |
4,472 |
$0.00 |